1. CRC 432 Subacute Care Pulmonary Rehabilitation

2. Pulmonary Rehabilitation  Goals –Maximize patient’s functional ability –Minimize impact in Patient Family Community –Improve quality of life –Control & alleviate symptoms

3. Pulmonary Rehabilitation  Historical Perspective –1951: Dr Barach recommended physical reconditioning for COPD patients Walk without becoming dyspneic –Barach was ignored; O 2 therapy & bed rest prescribed Skeletal muscle deterioration Fatigue & weakness Increased dyspnea Homebound, room bound, bed bound

4. Pulmonary Rehabilitation  Historical Perspective –1962: Pierce confirmed Barach –Pierce found that exercising COPD patients Decreased pulse Decreased respiratory rates Decreased minute ventilation Decreased CO 2 production Improved pulmonary function

5. Pulmonary Rehabilitation  Historical Perspective –Paez demonstrated Efficiency of motion Decreased O 2 consumption –Smoking cessation included –Education added Pathophysiology Equipment Medications

6. Pulmonary Rehabilitation  Scientific Basis –Focus on patient –Include clinical sciences Quantify degree of physiologic impairment Establish outcomes for reconditioning –Include social sciences Psychological Social Vocational

7. Pulmonary Rehabilitation  Physical Reconditioning –Exercise increases energy demands Increased circulation Increased ventilation Increased O 2 deliver Increase CO 2 elimination –If O 2 demands NOT met Blood lactate level increase CO 2 increases as lactic acid buffered Increased stimulus to breathe

8. Pulmonary Rehabilitation

9.  This point is called the “onset of blood lactate accumulation,” or OBLA  Abrupt rise in PaCO 2 & minute ventilation: called “ventilatory threshold”  Beyond V T, metabolism = anaerobic respiration (decreased NRG production efficiency, lactic acid rise, fatigue)

10. Pulmonary Rehabilitation  Physical Reconditioning –MVV index of respiratory system’s ability to handle increased physical activity –MVV = FEV 1 x 35 –Normal: 60%-70% of pred MVV during max exercise –Indicates adequate respiratory reserve –Indicates ventilation NOT primary limiting factor for ending exercise

11. Pulmonary Rehabilitation  Physical Reconditioning –MVV decreased with COPD –COPDs have limited exercise ability Increased CO 2 production Respiratory acidosis SOB O 2 consumption increases faster than normal

12. Pulmonary Rehabilitation  Physical Reconditioning –Rehab programs must: Physically recondition Increase exercise tolerance

13. Pulmonary Rehabilitation  Psychosocial Support –Indicators bettor predictors of frequency & LOS for COPD patients compared to PFTs –Psychosocial indicators better determine rehab program completion than physical reconditioning –COPD negatively affects person’s outlook on life –Can reduce motivation

14. Pulmonary Rehabilitation  Psychosocial Support –Depression/hostility occur with acute & chronic disease –Economic loss & fear of death produce hostility –Interaction among patients is beneficial –Patient’s lacking social support at higher risk for re-hospitalization –Intolerance for physical exertion lessens social activity

15. Pulmonary Rehabilitation  Psychosocial Support –Physical reconditioning & psychosocial support linked –Reducing exercise intolerance & improving cardiovascular response to exercise = independent, active lifestyle –Improve social importance & self-worth –Occupational training & job placement important

16. Pulmonary Rehabilitation  Program Goals –Control respiratory infection –Basic airway management –Improve ventilation & cardiac status –Improve ambulation & other physical activities –Reduce medical costs –Reduce hospitalizations

17. Pulmonary Rehabilitation  Program Goals –Reduce LOS when hospitalized –Reduce # of MD office visits –Provide psychosocial support –Occupational training/job placement –Family education, counseling, support –Patient education, counseling, support

18. Pulmonary Rehabilitation  PROGRAM OBJECTIVES –Development of diaphragmatic breathing skills –Development of stress management and relaxation techniques –Involvement in a daily physical exercise regimen to condition both skeletal and respiratory-related muscles –Adherence to proper hygiene, diet, and nutrition –Proper use of medications, oxygen, and breathing equipment (if applicable) –Application of airway clearance techniques (when indicated) –Focus on group support –Provisions for individual and family counseling

19. Pulmonary Rehabilitation  Chronic lung disease progressive & irreversible  Rehabilitation does NOT alter progressive deterioration  Rehabilitation improves utilization of O 2 by: –Increasing muscle use effectiveness –Promoting effective breathing techniques

20. Pulmonary Rehabilitation  O 2 cost for given amount of ventilation is excessive  Training skeletal muscle groups alone NOT beneficial  Training respiratory related muscles improves exercise tolerance

21. Pulmonary Rehabilitation  Evaluation of Rehabilitation Program Outcomes –Changes in exercise tolerance –Before and after 6 minute walking distance –Review of patient home exercise logs –Strength measurement –Flexibility and posture –Performance on specific exercises (e.g., ventilatory muscle, upper extremity) –Changes in symptoms –Dyspnea measurement comparison –Frequency of cough, sputum production, or wheezing –Weight loss or gain –Psychological test instruments

22. Pulmonary Rehabilitation  Evaluation of Rehabilitation Program Outcomes –Other changes –Activities of daily living (ADL) changes –Postprogram follow-up questionnaires –Preprogram and postprogram knowledge tests –Compliance improvement with pulmonary rehabilitation medical regimen –Frequency and duration of respiratory exacerbations –Frequency and duration of hospitalizations –Frequency of emergency department visits –Return to productive employment

23. Pulmonary Rehabilitation  Potential Hazards –Cardiovascular abnormalities Cardiac arrhythmias (can be reduced with supplemental oxygen during exercise) Systemic hypotension –Blood gas abnormalities Arterial desaturation Hypercapnia Acidosis –Muscular abnormalities Functional or structural injuries Diaphragmatic fatigue and failure Exercise-induced muscle contracture

24. Pulmonary Rehabilitation  Potential Hazards –Miscellaneous Exercise-induced asthma (more common in young patient with asthma than in patients with COPD) Hypoglycemia Dehydration

25. Pulmonary Rehabilitation  Patient Selection –Evaluation –Testing  Patient Evaluation –History (medical, psychological, vocational, social) –Questionnaire/interview form –Physical exam –CXR

26. Pulmonary Rehabilitation  Patient Evaluation –CBC –Electrolytes –Urinalysis –PFTs (spirometry, volumes, D L CO, pre/post) –Cardiopulmonary exercise evaluation Quantifies initial exercise capacity Provides basis for exercise prescription Renders baseline data for assessing progress Shows degree of hypoxemia/desat during exercise

27. Pulmonary Rehabilitation  Common Physiological Parameters Measured During Exercise Evaluation –Blood pressure –Heart rate –ECG –Respiratory rate –Arterial blood gases (ABGs)/O 2 saturation –Maximum ventilation (VEmax) –O 2 consumption (either absolute VO 2 or METS, the metabolic equivalent of energey expenditure) –CO 2 production (VCO 2 ) –Respiratory quotient (RQ) –O 2 pulse

28. Pulmonary Rehabilitation  Exercise Evaluation –Graded levels (ergometer or treadmill) –3-min intervals allow steady state –ABGs at rest & at peak exercise

29. Pulmonary Rehabilitation  Relative Contraindications to Exercise Testing –Patients who cannot or will not perform the test –Severe pulmonary hypertension/cor pulmonale –Known electrolyte disturbances (hypokalemia, hypomagnesemia) –Resting diastolic blood pressure > 110 mm Hg or resting systolic blood pressure > 200 mm Hg –Neuromuscular, musculoskeletal, or rheumatoid disorders exacerbated by exercise –Uncontrolled metabolic disease (e.g., diabetes) –SaO 2 or SpO 2 < 85% with the subject breathing room air –Untreated or unstable asthma

30. Pulmonary Rehabilitation  Indications for Pulmonary Rehabilitation –Symptomatic patients with COPD –Patients with bronchial asthma and associated bronchitis (asthmatic bronchitis) –Patients with combined obstructive and restrictive ventilatory defects –Patients with chronic mucocilliary clearance problems –Patients having exercise limitations due to severe dyspnea

31. Pulmonary Rehabilitation  Patient Selection –Ex-smokers –Smoking cessation program for smokers  Patients Excluded –Concurrent problems limit or preclude exercising –Condition complicated by malignant neoplasms, e.g., bronchogenic carcinoma

32. Pulmonary Rehabilitation  Program Design –Open-ended format Participate until predetermined objectives achieved No set timeframe Completed at patient’s pace Good format for self-directed patients Good format for schedule difficulties Good format for individual attention Lack group support/involvement

33. Pulmonary Rehabilitation  Program Design –Closed design Set timeframe (8 to 16 weeks; 1 to 3 sessions/wk) Insurance coverage may dictate length for which person qualifies Sessions last 1 to 3 hours Presentations formal Offer group support/involvement Schedule determines program completion

34. Pulmonary Rehabilitation  Content ComponentFocus Time Frame EducationWelcome (group interaction)5 mins Review of program diaries (past week’s activities)20 mins Presentation of education topic20 mins Questions, answers, and group discussion15 mins PhysicalPhysical activity and reconditioning45 mins ReconditioningIndividual goal-setting and session summary15 mins Total: 120 minutes (2 hours)

35. Pulmonary Rehabilitation  Physical Reconditioning –Excise prescription with target HR based on initial exercise evaluation –Target HR set using Karvonen’s formula –THR = [(MHR-RHR) x (50% to 70%)] + RHR

36. Pulmonary Rehabilitation  Physical Reconditioning MHR = 150 bpm RHR = 90 bpm THR = [(150 – 90) x (0.6)]+ 90 = 126 bpm

37. Pulmonary Rehabilitation  Exercise Prescription –Lower extremity aerobic exercises –Timed walking –Upper extremity aerobic exercises –Respiratory muscle training  Monitoring during Exercise –Pulse oximetry –Blood pressure

38. Pulmonary Rehabilitation  Lower Extremity –Walking (treadmill/flat surface) Goals for distance, time, grade on treadmill 6 minute flat surface/increase distance –Bicycling (stationary)  Upper Extremity –Arm ergometers –Rowing machines

40. Pulmonary Rehabilitation  Inspiratory resistance breathing device –Adjustable flow resistor –One-way valve –Inhale through restricted orifice (variable size) –Change inspiratory load –Exhalation through one-way valve

42. Pulmonary Rehabilitation  Instruction –Sit upright –Breathe slowly through device (10 – 12 bpm) –MIP < 30% of measured P i max, use next smaller orifice –Repeat effort until 30% is consistently achieved –1 or 2 daily sessions for 10 – 15 minutes/session –When 30% is consistently achieved, increase resistance –Increase session time to 30 minutes

43. Pulmonary Rehabilitation  Introduction and welcome, program orientation  Respiratory structure, function, and pathology  Breathing control methods  Relaxation and stress management  Proper exercise techniques and personal routines  Methods to ad secretion clearance (bronchial hygiene)  Home oxygen and aerosol therapy  Medications: their use and abuse  Medications: use of MDIs and spacers  Dietary guidelines and good nutrition  Recreation and vocational counseling  Activities of daily living  Follow-up planning and program evaluation  Graduation

44. Pulmonary Rehabilitation  Program Results –Evaluate Patient Program outcomes –Preprogram/current program status –Data Physiological Psychological Sociological